St.lukes casepress

Trinity University of Asia

St. Luke’s College of NursingE. Rodriguez Sr. Avenue, Cathedral Heights,

Quezon City, Philippines

“Sweet Glomerulus:A Case of Diabetic Nephropathy”

A Case Presented to the Faculty

of St. Luke’s College of Nursing

Trinity University of Asia

In Partial Fulfillment

of the Requirements for the

Degree of Bachelor of Science in Nursing

Submitted by:

Eximius

4NU02 Group 4

Bedania, Katrina- Physical Assessment, Gordon’s Functional

Belino, Jan Justin-Drug Study

Bello, Reina Azaleah- Laboratory, Theoritical Framework and 1NCP

Benitez, Mark Angelo- Chapter 1 and 2, 1 NCP

Bernardo, Charles Joseph- Chapter 8 and 1 NCP

Bersabal, Crystal Mae- Anatomy and Pathophysiology,

Theoritical Framework,Compilation and powerpoint

“Sweet Glomerulus: A Case of Diabetic Nephropathy”

Chapter 1

1.1 Objectives

1.1.1 General Objectives

This case study about Diabetic Nephropathy is geared towards the enhancement of the student

nurses’ knowledge skills and attitude in promoting the well-being of a patient, as well as the prevention of

the progression of the disease and other life threatening complications.

1.1.2 Specific Objectives:

In accordance to the general objective the researchers aim the following goals:

Knowledge

To broaden the student’s knowledge regarding the aspects of Diabetic Nephropathy such as, it’s

contributing factors, pathophysiology, signs and symptoms, related diagnostic procedures and laboratory

examinations, complications, pharmacologic and non-pharmacologic intervention associated with the

disease.

Skills

To improve the student’s skills in handling a patient with Diabetic Nephropathy specifically in

performing focused assessment for the clients and to prepare appropriate nursing interventions and to

determine the suitable health teachings.

Attitude

To be able to develop positive and caring attitude towards patient with Diabetic Nephropathy.

And to develop the outlook of the students on the said illness as to its effects to the patients and to the

society.

1


Chapter 2

2.1 Background of the Study

This is a case of Mr. L.T. a 71 yrs. old male. He was on ICU 4 at St. Luke’s Medical Center.

Initially he was admitted last November 28, 2010 via stretcher borne in the Emergency Room of St.

Luke’s Medical Center. His chief complaint was hematochezia, with a diagnosis of CKD 2* to DM/HPN

Nephropathy and maintenance of Hemodialysis for 2 years management + DM Foot on the right foot, s/p

disarticulation 3rd to 5th digit of the right foot.

The presenters decided to focus on the Diabetic Nephropathy, The presenters aim for the readers

to be aware of the nature of the Diabetic Nephropathy, how it is developing; the cause and effect; its risk

factors; the different signs & symptoms and the management (medical, surgical, nursing) that can be done

to the this condition. It can also be a foundation on how this condition can affect different body systems

that further can lead to different complications. The paper hopes to serve as a reminder that this condition

is simply occurring.

This paper can also serve as guideline or a basis for future presenter that would be presenting the

same condition.

2.2 Definition of the Case

Diabetic nephropathy, also known as Kimmelstiel-Wilson syndrome, or nodular diabetic

glomerulosclerosis and intercapillary glomerulonephritis, is a progressive kidney disease caused by

angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and diffuse

glomerulosclerosis. It is due to longstanding diabetes mellitus. Diabetic nephropathy typically affects the

network of tiny blood vessels the microvasculature in the glomerulus, a key structure in the kidney

composed of capillary blood vessels. The glomerulus is critically necessary for the filtration of the blood.

Features of diabetic nephropathy include the nephrotic syndrome with excessive filtration of protein into

the urine, high blood pressure, and progressively impaired kidney function. When it is severe, diabetic

nephropathy leads to kidney failure, end-stage renal disease, and the need for chronic dialysis or a kidney

transplant.

2

http://www.medterms.com/script/main/art.asp?articlekey=10419

http://www.medterms.com/script/main/art.asp?articlekey=378

http://en.wikipedia.org/wiki/Diabetes_mellitus

http://en.wikipedia.org/wiki/Nephrotic_syndrome

http://en.wikipedia.org/wiki/Glomerulus

http://en.wikipedia.org/wiki/Kidney

http://en.wikipedia.org/wiki/Capillary

http://en.wikipedia.org/wiki/Angiopathy

http://en.wikipedia.org/wiki/Kidney_disease


2.3 Clinical Manifestations

edema: swelling, usually around the eyes in the mornings; later, general body swelling may

result, such as swelling of the legs

foamy appearance or excessive frothing of the urine (caused by the proteinura)

unintentional weight gain (from fluid accumulation)

anorexia (poor appetite)

nausea and vomiting

malaise (general ill feeling)

fatigue

headache

frequent hiccups

generalized itching

Approximately 25% to 40% of patients with DM 1 ultimately develop diabetic nephropathy (DN), which

progresses through about five predictable stages.

1. Stage 1 (very early diabetes)—Increased demand upon the kidneys is indicated by an above-

normal glomerular filtration rate (GFR).

2. Stage 2 (developing diabetes)—The GFR remains elevated or has returned to normal, but

glomerular damage has progressed to significant microalbuminuria (small but above-normal level

of the protein albumin in the urine). Patients in stage 2 excrete more than 30 mg of albumin in the

urine over a 24-hour period. Significant microalbuminuria will progress to end-stage renal disease

(ESRD). Therefore, all diabetes patients should be screened for microalbuminuria on a routine

(yearly) basis.

3. Stage 3 (overt, or dipstick-positive diabetes)—Glomerular damage has progressed to clinical

albuminuria. The urine is "dipstick positive," containing more than 300 mg of albumin in a 24-

hour period. Hypertension (high blood pressure) typically develops during stage 3.

4. Stage 4 (late-stage diabetes)—Glomerular damage continues, with increasing amounts of protein

albumin in the urine. The kidneys' filtering ability has begun to decline steadily, and blood urea

nitrogen (BUN) and creatinine (Cr) has begun to increase. The glomerular filtration rate (GFR)

decreases about 10% annually. Almost all patients have hypertension at stage 4.

3

http://www.cardiologychannel.com/hypertension/index.shtml

http://en.wikipedia.org/wiki/Itching

http://en.wikipedia.org/wiki/Hiccup

http://en.wikipedia.org/wiki/Headache

http://en.wikipedia.org/wiki/Fatigue_(physical)

http://en.wikipedia.org/wiki/Malaise

http://en.wikipedia.org/wiki/Vomiting

http://en.wikipedia.org/wiki/Nausea

http://en.wikipedia.org/wiki/Anorexia_(symptom)

http://en.wikipedia.org/wiki/Eye

http://en.wikipedia.org/wiki/Edema


5. Stage 5 (end-stage renal disease, ESRD)—GFR has fallen to approximately 10 milliliters per

minute (<10 mL/min) and renal replacement therapy (i.e., hemodialysis, peritoneal dialysis,

kidney transplantation) is needed.

Progression through these five stages is rather predictable because the onset of DM 1 can be identified,

and most patients are free from age-related medical problems.

An estimated 5% to 15% of DM 2 cases also progress through the five stages of diabetic nephropathy

(DN), but the timeline is not as clear. Some patients advance through the stages very quickly.

2.4 Etiology

The exact cause of diabetic nephropathy is unknown, but it is believed that uncontrolled high

blood sugar leads to the development of kidney damage, especially when high blood pressure is also

present.

A variety of factors contribute to the renal damage seen in diabetes. By definition, hyperglycemia

is a common etiologic factor in diabetic patients with nephropathy, but a genetic predisposition and

smoking contribute as well. Most significant, however, is the presence of hypertension, not only before

and after the onset of microalbuminuria but probably also as another familial marker of risk, since

patients with diabetes and a positive family history of hypertension are at higher risk of nephropathy.

2.5 Incidence

Persons with diabetes who have the following risk factors are more likely to develop this condition:

African American, Hispanic, or American Indian origin

Family history of kidney disease or high blood pressure

Poor control of blood pressure

Poor control of blood sugars

Type 1 diabetes before age 20

Smoking

4


Chapter 3

3.1 Patient’s Profile

Name: Patient L.T.

Age: 71 years old

Height: 150cm

Weight: 60kg

Birthday:

Gender: Male

Address: Maria Clara St. Talayan Village Quezon City

Religion: Roman Catholic Individual

Nationality: Filipino

Civil Status: Married

Occupation: None

Date of Admission: November 28, 2010

Time of Admission: 12:39pm

Mode of Admission: via wheelchair

Admitting Diagnosis: UGIB/LGIB Chronic Kidney Disease 2* to DM/HPN Nephropathy

Final Diagnosis: CKD 2* to DM/HPN Nephropathy and maintenance of Hemodialysis for 2 years

management + DM Foot on the right foot, s/p disarticulation 3rd to 5th digit of the right foot.

Admitted under the service of: Dr. Sanosa, Maurice Lualhati

Initial Vital Signs:

Blood Pressure= 90/60 mmHg

Temperature= 36.5°C

Pulse Rate= 84 beats per minute

Respiratory Rate= 20 cycles per minute

3.2 CHIEF COMPLAINT

Hematochezia

5


3.3 PAST HISTORY OF ILLNESS

Patient T.L. was known to be a hypertensive and diabetic. Patient T.L. was (+) HPN for 40 years

with a Combizar for his maintenance drug. And (+) Diabetes Mellitus for 40 years without medicine

taken. The patient was also having his hemodialysis for 2 years

3.4 PRESENT HISTORY OF ILLNESS

3 days prior to admission, patient L.T. noticed to have a blood in his stool followed by episodes

of chest tightness and diaphoresis and dizziness prompting to admission. The patient was admitted due to

hematochezia and referred with cardiology for cardio management due to Troponin I on admission.

The patient was having a CKD 2* to DM/HPN Nephropathy and maintenance of Hemodialysis

for 2 years management + DM Foot on the right foot, s/p disarticulation 3rd to 5th digit of the right foot.

He was brought to St. Luke’s Medical Center’s Emergency Room by his family, with an initial vital signs

BP=90/60 mmHg, Temperature= 36.5°C, PR= 84 beats per minute, RR=20 cycles per minute. He was

then admitted at 11:39pm in the Intensive Care Unit.

ALLERGIES

The patient had no known allergies

3.6 PERSONAL AND SOCIAL HISTORY

Prior to admission the patient does not have any vices reported.

3.6 FAMILY HISTORY

The patient does not have any history in the family of any diseases.

PHYSICAL ASSESSMENT (Cephalo- caudal assessment)Initial Vital Signs:BP: 90/60 mmHg Cardiac Rate: 84 beats/ minTemperature: 36.5° C Respiratory Rate: 20 cycles per minute

RESULTS1.) HEENT a.) Head - hair color was gray, black, and white.

6


- exhibited partial hair loss that recedes the hair line due to old age. b.) Eyes - symmetrical, unicteric sclera with pink palpable conjunctivae

- Pupil equally round reactive to light and accommodation - Pupil size: 2mm, brisk

c.) Ears - no hearing impairment noted- no hearing aid used- no discharge present

d.) Nose - no nasal deviation noted- no discharge present.-with nasal cannula @ 4L/m

e.) Throat -no obstruction-no lesions-no masses

f.) Mouth - no dentures- with dry mouth-with some dental carries

2.) SKIN -with IV catheter inserted at right metacarpal vein -with CVP on the right neck connected at intrajugular catheter-with arterial-venous fistula at the right neck (intrajugular)-with brachial fistula at the left arm-with blackish discoloration at the right and leg foot

BRADEN SCALE:> Sensory Perception: 3- slightly limited> Moisture: 3- occasionally moist> Activity: 2- chairfast>Skin friction: 2- potential problem> Mobility: 3- slightly limited> Nutrition: 3- adequate TOTAL SCORE: 16, if the patient is <18 patient’s is at risk: initiate prevention

3.) NEUROLOGICAL -conscious and coherent-not in distress- GCS: > Motor response: 6- obeys command > Verbal response: 5- oriented > Eye opening: 4- spontaneous TOTAL SCORE: 15- Pupil equally round reactive to light and accommodation - Pupil size: 2mm, brisk

4.) RESPIRATORY - with nasal cannula @ 2L/min- with spontaneous unlabored breathing but with epiodes of tachypnea- with clear breath sounds- symmetric chest expansion- RR: 20 cpm

5.) CARDIOVASCULAR

- with intrajugular catheter at the right neck- normal heart sounds and regular rhythm auscultated with a CR: 80 bpm-ECG: sinus rhythm with isolated PVCs- with regular and strong pulse palpated on the radial and brachial artery.

7


- Blood Pressure on lying position: right= 90/60 mmHg - no edema observed- (-) homan sign

6.) GASTROINTESTINAL

- on 1800 kcal/ soft Dm diet 2g Na 72g CHON 3 meals and 2 snacks/day- Abdomen soft, non tender, not distended - with normal bowel sounds= 15 bowel sounds/min- patient is constipated for 3 days relieved by Lactulose

7.) MUSCULOSKELETAL

- Lovets: Right arm- 4/5 Left arm- 4/5 Right leg- 4/5 Left leg- 4/5- with slight weakness- with Functional Level II: Requires help from another person for assistance, supervision or teaching- with disarticulation of 3rd to 5th digit at Right foot

8.) GENITOURINARY -with ongoing CRRT

Gordon’s Functional

Gordon’s Functional BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Health perception and health management pattern

According to the patient’s wife, patient was diabetic and hypertensive for the past 40 years up to the present. The patient has started his dialysis since June 2009. The patient has drug maintenance on his hypertension which is the Combizar but did not give much attention on managing his diabetes.

The chief complaint of the patient was hematochezia but when the student nurses handled the patient, no hematochezia and other episodes of bleeding has been reported.

Nutritional and metabolic pattern

Patient was fond on eating foods high in salt, sugar and fat. But regularly eats vegetables.

The patient is eating well and has a good appetite. His current diet was 1800 kcal/ soft Dm diet 2g Na 72g CHON 3 meals and 2 snacks/day.

Bowel-elimination pattern

Patient had episodes of hematochezia that prompted him to be admitted.

The patient is in a complete bed rest. He wears a diaper. Patient L.T. is currently undergoing a CRRT. He only defecates once in 2- 3 days, to address this, the doctor gives Latulose 30cc @ HS.

8


Activity exercise pattern

According to the patient’s wife, the patient was not doing his regular exercise but rather chooses to walk around, rest and watch the television.

The patient has slight weakness on his extremities. He is in a complete bed rest and has a functional level of II: Requires help from another person for assistance, supervision or teaching.

Sleep-rest pattern

The patient has a regular 8 hours of sleep every day. According to the relative, the patient takes his nap during is his free time.

During hospitalization, the patient was receiving the right amount of rest he can get. The patient sleeps continuously except when the time the nurse or the doctor goes inside his room for their rounds, gets vital signs, and give medications. The patient also takes naps in the morning or in the afternoon.

Cognitive-perceptual pattern

The patient doesn’t have any hearing difficulties and doesn’t wear any hearing aids.

Patient T.L. has no difficulties in recognizing things. He is being visited by his wife and their helper. The patient can respond accordingly and verbalizes any discomfort.

Role relationship pattern

The patient is happily married. His daughter and son have their own families already. He is a land owner at Catanduanes city.

During hospital stay, his wife and their helper take turns to accompany the patient. The patient’s family is the one who supports the patient’s need, whether it is physically, emotionally and financially.

Sexuality reproductive pattern

NOT APPLICABLE NOT APPLICABLE

Coping stress tolerance pattern

Patient’s favorite past time was watching the television and taking naps during his free time.

During hospitalization, patient watches television to lessen his boredom and take his naps whenever he wants to.

Value-belief pattern

The patient is a Roman Catholic and is faithful with God. Before he was admitted he regularly visited the church every Sunday.

According to the patient’s wife, they believe that everything will be fine with God’s faith.

9


Chapter 4

4.1 Anatomy and Physiology

The kidneys are the primary organs of

the urinary system in vertebrates. The

kidneys filter theblood, remove the wastes,

and excrete the wastes in theurine. About

1,300 milliliters of blood flow through the

kidneys each minute (about 400 gallons a

day). From this blood the Malphigian

corpuscles extract about 170 liters of filtrate

a day. As this fluid passes down the

uriniferous tubules it is almost all

reabsorbed. Only about 1.5 liters are left in

the tubules to carry away the waste products. The whole blood supply passes through the kidneys every 5

minutes, ensuring that waste materials don't build up. The renal artery carries blood to the kidney, while

the renal vein carries blood, now with much lower concentrations of urea and mineral ions, away from the

kidney. The urine formed passes down the ureter to the bladder. The work of the kidneys is much more

than just the removal of waste, however. Other functions of the kidneys include:

•Helping control the amount of water lost to the outside world – most important in land animals.

•Helping regulate thepH (i.e., level of acidity or alkalinity) ofthe blood and the general balance of ions in

the blood, andhence in the body fluid as a whole.

•Conserving essential substances such asglucose andamino acids.

Parts and Function:

Renal Vein

This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand

side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get

rid of excess

amino-acids. Blood in the renal vein also has exactly the right amount of water and salts. This is because

the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our

10


blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is

excreted.

Renal Artery

This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must

contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal

artery must have sufficient pressure or the kidney will not be able to filter the blood. Blood supplied to

the kidney contains a toxic product called urea which must be removed from the blood. It may have too

much salt and too much water. The kidney removes these excess materials; that is its function.

Pelvis

This is the region of the kidney where urine collects.

Ureter

The ureter carries the urine down to the bladder.

Medulla

The medulla is the inside part of the kidney. This is where the amount of salt and water in your urine is

controlled. It consists of billions of loops of Henlé. These work very hard pumping sodium ions. ADH

makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine

is produced.

Cortex -The cortex is the outer part of the kidney. This is where blood is filtered. We call this process

"ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the

renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of

capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red

blood cells, white blood cells, platelets and fibrinogen stay in

the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of

liquid every 24 hours. Most of this liquid, which we call "ultra-filtrate" is reabsorbed in the medulla and

put back into the blood.

Glomerulus and Bowman's capsule

This is where ultra- filtration takes place. Blood from the renal artery is forced into theglomerulus under

high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which

surrounds it. This does not work properly in people who have very low blood pressure.

Proximal Convoluted Tubules

Don't worry about remembering the name for your GCSE biology. Jolly good though ifyou can. Proximal

means "near to" and convoluted means "coiledup" so this is the coiled up tube near to the Bowman's 11


capsule. This is the place where all that useful glucose is reabsorbed from the ultra-filtrate and put back

into the blood. If the glucose was not absorbed it would end up in your urine. This happens in people who

are suffering from diabetes.

Loop of Henlé

This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time

pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low

water concentration. If you remember the definition of osmosis, you will realize that water will pass from

a region of high water concentration (the ultra-filtrate and urine) into a region of low water concentration

the medulla) through cell membranes which are semi-permeable.

Distal Convoluted Tubules

Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where

most of the salts in the ultra-filtrate are re-absorbed.

Collecting Duct

Collecting ducts run through the medulla and are surrounded by loops of Henlé. The liquid in the

collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our

kidneys make about 160 litres of urine every 24 hours, we only produce about ½ litre of urine. It is called

a collecting duct because it collects the liquid produced by lots of nephron.

12


PATHOPHYSIOLOGY

13


Chapter 5

5.1 Laboratory

Laboratory Test 11/28

11/29

11/29

7pm

11/30

11/303:30pm

12/1 Significance

Hb M: 13-17g/dlF: 11.6- 15.5 g/dl

5.2 8.2 7.5 10.5 There is a decrease in the hemoglobin levels maybe due to fluid retention

HctM: 40-52 vol%F: 36-47vol%

18.2 24.9 22.9 31.7 There is a decrease in the hematocrit levels due to decrease blood volume due to the decrease ability of the kidney to function.

RBCM: 4.7- 6.1 mil/mm3F: 4.2-5.4 mil/mm3

1.96 2.79 2.53 3.49 There is a decrease in the RBC levels due to a decrease levels of hemoglobin causing low production of RBCs.

WBC4,800-10,800mm3

7,610

10,310

14,000

18,500

The first two columns show that there are normal levels but on the later columns there is a significant increase in the WBC levels meaning there is an infection occurring inside the body.

Eosinophils 0.7% 1 There is an increase in the number of the eosinophil level might be due to an increase in the histamine level in the body and infection in the body.

Neutrophils 40-74%

76 86 91 94 There is an increase in the number of neutrophils that signifies that there is a bacterial infection in the body.

Lymphocytes 19-48%

16 7 4 3 There is a decrease in the number of lymphocytes which means that the patient is immunocompromised.

Monocytes 3-9% 7 7 5 3 Monocytes are within normal levels.Platelet 130,000-500,000/mm3

255,000

154,000

131,000

119,000

The platelet count started with a normal range but on the last column there is a significant decrease in the number of platelet which means the patient is at risk for bleeding or easy bruising.

Crea M: 0.8-1.3 mg/dl

6.94 3.96 3.33 2.63 There is an increase in the Creatinin levels due to the patient’s renal

14


F: 0.6-1.0 mg/dlM/F: 0.7-1.5 mg/dl

disease.

BUN 7.18 mg/dl7.21 mg/dl

71 41 42 38 There is an increase in the BUN levels due to the patient’s renal disease.

Protime:Patient Control 12-14sec%activity 70-100%

12.211.1 or 96.7NSR 0.93

Results are within normal range.

PTT 28-44sec 34.2 Result is within normal range.Sodium 135-145 mmol/L

138 134 134 136 133 Results are within normal range.

Potassium 3.6-5.5 mmol/L

3.7 5.4 5.2 5.2 5.4 Results are within normal range.

Chloride 98-107 mmol/L

101 99 97 Results are within normal range.

Calcium 8.4-10.2 mg%

1Ca 0.89

8.81Ca 0.99

0.92 1Ca 0.90

There is a decrease in calcium levels therefore indicating a kidney problem.

Phosphorus 2.5-4.5mg %

4 Result is within normal range.

Magnesium 1.8-2.4mg/dl1.7-2.2mg/dl

1.8 1.9 1.9 Results are within normal range.

SGPT 30-65U/L7-56U/L

27 SGPT has a decreased level because of the decreased ability of the liver to function.

SGOT 15-37U/L5-40U/L

103 SGOT has an increased level due to liver damage.

Alk Phos 50-436 U/L38-126 U/L


Bilirubin 0-1mg/dl0.2-1.3mg/dl

0.45 Result is within normal range.

Direct Bil 0-0.3mg/dl0-0.4mg/dl

0.16 Direct bilirubin level is elevated therefore the liver was not able to excrete the bilirubin thus an indication of bile duct obstruction.

Indirect Bil 0.2-0.8mg/dl0.1-1.1mg/dl

0.29 Indirect bilirubin level is elevated therefore there is a lack of bilirubin clearance by the liver or hemolysis.

Total Protein 6.4-8.2g/dl

6.29 Result is within normal range.

Albumin 3.4-5g/dL3.9-5g/dL


Globulin 1.5-3g/dL

3.20 A high result of increase in globulin levels indicates a severe dehydration

15


and an underlying disease.A/G Ratio 1.5-2.5 0.9 There is a decrease in the A/G Ratio

level an indication of a kidney and liver disease.

Tropi 9.61 The troponin level is elevated due to the patient’s kidney disease.

FBS 429 FBS level is increased due to increase glucose levels in the blood.

HCO3 25 22 22 22 Result is within normal range.

16


Chapter 6

6.1 Drug Study

Medication Route/Dosage

Classification/Action

Indications/Contraindications

Adverse Effects

Nursing Considerations

CeftazidimeBrand names:zeptrigen

IV1g OD

Third generation cephalosporin. Binds to bacterial cell wall and cell membrane, causing bacterial death.

Indications: Prophylaxis

against possible infections.

Contraindications: known drug

allergies to cephalosporins

CNS: Seizures

Dermatologic: Rashes Urticaria

GI: Nausea Vomiting Cramps

Assess for current infections

Obtain a history to determine use of and reactions to penicillins or cephalosporin.

Check for renal dysfunctions

Observe therapeutic effects of drugs. As well as any adverse reactions to the drugs.

Epoietin BetaRecormon

IV500g SQ 3 times a week

Hematopoietic drug. Mimics effect oferythropoietin.Functions asgrowth factor,enhancing RBCproduction

Indications: Anemia

Contraindications: Allergy to any

component of Recormon

Unmanaged HPN

CNS: Dizziness Paresthesia Headache Seizures

GI: Nausea Abdominal discomfort

vomiting

CV: Hypertension Edema Increased

Assess patients extent of anemia.

Assess patient’s VS especially blood pressure

17


clotting

Esomeprazole

Brand names:Nexium

PO40mg BID

Proton pump inhibitorAntisecretory agent

Indications: GERD Hypersecretory

conditions

Contraindications: Known drug

allergy

CNS: Headache Dizziness Asthenia Vertigo Insomnia Apathy Anxiety Paresthesias Dream

abnormalities

Respiratory: URI symptoms Cough Epistaxis

Dermatologic: Rash Inflammation Urticaria Pruritus Alopecia Dry skin

GI: Diarrhea Abdominal

pain Nausea Vomiting Constipation

Check for hypersensitivity to Esomeprazole or any of its components

Check for skin lesions, and urinary exam

Administer 30 mins before meals.

Advise patient to swallow the tablet whole.

Administer antacids if needed.

Isosorbide DinitrateIsordil

IV5mg for chest pain

Cardiac medication, Nitrate Vasodilator. Decreases preload and lowers oxygen requirement for cardiac muscles.

Indications: Angina

Contraindications: Hypersensiti

vity to Isosorbide Dinitrate or any of its components.

CNS: Headache Agitation Confusion Tremors Anxiety Lack of

coordination

CV: Cardiac

arrythmias Congestive

heart failure. Palpitation

Assess Cardiac functions prior to administration.

Monitor Cardiac rhythm for abnormalities

Advice patient not to chew medication.

18


Hypotension

GI: Vomiting Nausea Constipation Gastritis

Theoretical Framework

Florence Nightingale’s Environmental Theory

She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969), that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development.

Defined in her environmental theory are the following factors present in the patient's environment:

Pure or fresh air Pure water Sufficient food supplies Efficient drainage

19


Cleanliness Light (especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status.

The factors posed great significance during Nightingale's time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. Also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient

The environmental theory of Florence Nightingale is the theory of choice for this patient because the St. Luke’s Medical Center specifically the ICU Unit provided the needed environment to enhance the condition of the patient such as providing the right interventions, giving the right care and equipments that will sustain the patient’s condition, maintaining a well environment and having a health care team that monitor’s the patient well and accurately.

NURSING CARE PLANS

20


Assessment Diagnosis Planning Intervention Rationale Evaluation OBJECTIVE:

-Bedridden-Age of 71 years

old-Lovett’s score:

4 in all extremities

-With hemodialysis and other contraptions

Risk for injury r/t prolonged immobility.

SHORT TERM: After 1 hour of nursing interventions, the patient and relative will verbalize understanding on different preventive

INDEPENDENT:- Assess for

level of consciousness. Noting for altered mental status.

- Determine the condition and

- To determine the condition of patient’s ability to cooperate and to monitor for the probability of injury or falls.

SHORT TERM: After 1 hour of nursing interventions, the patient and relative verbalized and showed an understanding on different

21


measures from injury.

LONG TERM: After 3 days of nursing interventions the patient will be free from injury.

age of patient.

- Assess muscle strength.

- Monitor patient on intervals.

- Identify safety factors.

- Maintain side rails up at all times.

- Provide pillows on the side of the patient.

- Maintain a well lighted and ventilated environment.

- Keep patient at rest.

- Attend needs and assistance.

COLLABORATIVE:- Encourage the

patient’s relative to stay with the patient at all times.

- To identify interventions needed.

- To determine ability to do gross and fine motor coordinations and movements.

- To monitor

changes, activities and movements. To prevent further complications.

- To promote an early prevention from injury and complications.

- To reduce the risk for falls that might cause harm to patient.

- To provide cushion and prevent from bumps to side rails.

- To enhance patient’s comfort and to monitor/see patient easily.

- To reduce fatigue.

- To reduce the risk for fractures, falls,

preventive measures from injury and complications.

LONG TERM: After 3 days of nursing interventions the patient was free from injury and complications as manifested by:(-) bruise(-) fracture (-) woundsAnd no complaints of falls, pain or other complications.

22


- Instruct the patient’s relative to call for assistance when moving the patient.

bruises and wounds.

- To attend needs and assistance.

- To lessen the chance for complications.

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:

Objective:> Creatine level= 6.9, 3.96, 3.33, 2.63

> Patient is undergoing CRRT/ SLED

Ineffective Tissue Perfusion (Renal) related to interruption of blood flow as a result of abnormal levels of BUN and Creatinine

Short Term:Within 8 hours of nursing intervention, the patient will verbalize his understanding regarding compliance to his therapy management (hemodialysis).

Independent:-Monitored vital signs especially BP

-Assess patient’s IJ catheter

-Maintained patient on a

- Indication of blood flow

- Assess for proper functioning and observe for any infection at the site.

-To promote maximum chest expansion.

Short Term:Within 8 hours of nursing intervention, the patient was able to verbalize his understanding “kelangan ko to para maging malinis ang dugo ko”.

23


> BUN level= 71, 41, 42, 38

> BP= 110/68

> Oliguria (<30 cc/hr)

Long Term:Within 3 days of nursing intervention, the patient will continue to undergo treatment and will show signs of improved perfusion.

moderate high back rest.

- Limit protein intake

Dependent:-CRRT/ SLED as ordered

- Strict monitoring of the dialysis machine and writing accurate results

-Administered Epoetin Beta 5,000 IU SQ 3x a week

Collaborative:-Instruct relatives regarding the compliance of therapy management.

- Helps decrease levels of BUN.

- Indicated for filtering the blood and excreting its waste products.

- To check for input and output

- Stimulates erythropoesis for production of new red blood cells.

-Hemodialysis may be a long term treatment.

Long Term:Within 3 days of nursing intervention, the patient was able to show signs of improved perfusion:Creatinine= from 6.9 to 2.63BUN= from 71 to 38BP= 124/93

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective:

-Episodes of hematochizea and melena.

-Patient was having Heparin drip 50 unit/hr.

-ACT -467

Risk for bleeding related to increase ACT.

Short Term:

Within 2 hours of nursing intervention, the patient will able to understand and verbalize about the proper

Independent:

-Monitor patient blood pressure.

-Monitor patient ACT

-May indicate internal bleeding.

-To monitor the patient clotting

Short Term:

Within 2 hours of nursing intervention, the patient was able to understand and verbalize about the proper

24


secs. (120-210 secs)

-Left brachial AV Fistula

management with his condition.

Long Term:

Within 8 hours of nursing intervention, the patient will not report any sign and symptoms of bleeding.

Dependent:

-Refer the patient ACT result.

-Lower the dose of heparin from 50 units/hr as ordered.

-Repeat ACT after 1 hour as ordered.

Collaborative:

-Provide patient a soft brittle tooth.

-Provide a left arm precaution for her AV Fistula.

time.

-To inform the doctor with the patient’s condition.

-because heparin is an anticoagulant that can contribute for the episode of bleeding.

-To monitor the patient ACT.

-Using the usual toothbrush can aggravate the bleeding in his gums.

-The fistula can be rupture.

management with his condition.

Long Term:

Within 8 hours of nursing intervention, the patient was not report any sign and symptoms of bleeding.

25


Chapter 7

7.1 Discharge Planning

Medication

Follow-up medications needed by the patient after discharge.

Allow patient and patient’s relative to learn about each drug he will be taking at

home.

Discuss to the patient and patient’ relative what the precautions when taking the

drugs are.

26


Environment

The importance of safe environment will be emphasized to the family members.

A hazard free environment allows the patient to have maximum independence

and sense of autonomy

Calm and restful environment must be maintained to reduce stress to the patient’s

condition

Treatment

• A caring attitude should be given to the patient

• Encourage the patient to perform activities he can tolerate to strengthen his

muscles

Health Teaching

Range of motion exercises can promote musculoskeletal stabilization and

strength.

Educate the clients relatives about the importance of consultation to monitor his

condition

Out- patient

The nurse and other health professionals can do follow-up care at home.

Advice the patient’s relative when to return for follow-up.

It is important for the hospital nurse to communicate the client’s needs to the

family or aide who will care for the client at home.

Educate the patient’s relative about the signs and symptoms that need urgent

medical attention.

Diet

Advice the patient’s relative to decrease intake of calories and protein (diabetic

diet)

Advice the patient’s relative to minimize intake of foods high in salt and fats

Spiritual

Encourage the patient’s relative to have an open relationship with God through

prayers.

Instill in patient’s relatives the importance of faith and hope.27


Encourage the relative to involve the patient in religious activities

Chapter 8

8.1 Nursing Implication

Nursing Research

The ultimate purpose of nursing is to provide high-quality patient care. Clinical practice

without research is practice based on tradition without validation. Research is needed to

evaluate the effectiveness of nursing treatment modalities, to determine the impact of nursing

care on the health of the patients or to test out theory. Nursing practice is undergoing

tremendous changes and challenges. Nursing research is defined as the application of

28


scientific inquiry to the phenomena of concern to nursing. The systematic investigation of

patients and their health experience is the primary concern of nursing.

This study will be a great contribution for nursing research. Future researchers of this

topic will benefit from this study by using this research as their reference and this can also

serve as a background of their study. It can also help future researchers to improve their work

and will help them to deepen their studies. This can also serve as a guide on decision making

regarding the prioritization in this research work.

Nursing Education

This study will help nursing students to broaden their knowledge regarding Diabetic

Nephropathy. This will give them a glimpse of what this disease is and will help them to

further understand the said topic. This study will give them additional knowledge that they

may not gain from their lectures.

Nursing Practice

Nursing practice will gain further improvement in this case study regarding Diabetic

Nephropathy. This study will contribute additional knowledge to the readers especially

nurses by stressing the effects of the disease to the patient’s body and its pathophysiology.

This study may serve as a point of reference to any other related course in nursing field to

promote progress and excellence of one’s skills in executing any nursing intervention.

Equipped with the essential knowledge about the disease may increase the nurse’s confidence

in accomplishing every structured intervention followed in nursing care plan. This research

can also improve the quality of nursing care that is rendered to the patients.

29

Documents

St.lukes casepress